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Background Objectives Methods Results Conclusions Invasive aspergillosis (IA) can lead to life‐threatening respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) support. However, data on ECMO experience in the management of IA patients are scarce.The purpose of this systematic review was to evaluate the potential benefits and risks of ECMO as a supportive intervention for critically ill patients with IA.We conducted a systematic review of the literature using the search terms ECMO, extracorporeal membrane oxygenation, Aspergillus and Aspergillosis in two databases (Medline and Scopus). Clinical data were extracted by two independent investigators. Clinical parameters, such as mode of ECMO support, duration of treatment and clinical outcomes, were assessed.Overall, 32 patients were included in the analysis. The age ranged from 5 to 69 years, 59% were male, and 38% were female. The majority of patients suffered from ARDS (82%). 82% received VV‐ECMO, and 18% received VA‐ECMO. Aspergillus fumigatus was the most frequent cause of IA, coinfections were frequently observed (51%). The overall mortality was 78%. Complications during ECMO support were observed in 21 of the 39 cases (53.8%).IA poses significant management challenges for critically ill ICU patients, even with ECMO support. Although ECMO appears to improve survival of patients at high risk of AI, potential risks such as bacterial superinfection and altered pharmacokinetics of antifungal drugs must be carefully considered. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Barotrauma is a frequent complication in patients with severe respiratory failure and is associated with poor outcomes. Extracorporeal membrane oxygenation (ECMO) implantation allows to introduce lung‐protective ventilation strategies that limit barotrauma development or progression, but available data are scarce. We performed a scoping review to summarize current knowledge on this therapeutic approach.We systematically searched PubMed/MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies investigating ECMO as a strategy to prevent/limit barotrauma progression in patients with respiratory failure. Pediatric studies, studies on perioperative implantation of ECMO, and studies not reporting original data were excluded. The primary outcome was the rate of barotrauma development/progression.We identified 21 manuscripts presenting data on a total of 45 ECMO patients. All patients underwent veno‐venous ECMO. Of these, 21 (46.7%) received ECMO before invasive mechanical ventilation. In most cases, ECMO implantation allowed to modify the respiratory support strategy (e.g., introduction of ultraprotective/low pressure ventilation in 12 patients, extubation while on ECMO in one case, and avoidance of invasive ventilation in 15 cases). Barotrauma development/progression occurred in <10% of patients. Overall mortality was 8/45 (17.8%).ECMO implantation to prevent barotrauma development/progression is a feasible strategy and may be a promising support option. [ABSTRACT FROM AUTHOR]

Aims Methods and results Conclusions Impella has become a new option for mechanical circulatory support in patients with cardiogenic shock (CS); however, prognostic models for patients after Impella are lacking. We aimed to identify the factors that predict in‐hospital mortality in patients with CS requiring Impella and develop a new risk prediction model.We utilized the J‐PVAD registry, which includes all cases where Impella was implanted in Japan. Two‐thirds of the patients in the J‐PVAD registry were randomly assigned to the derivation cohort (n = 1701), and the other third was assigned to the validation cohort (n = 850). A backward stepwise logistic regression model was developed to identify factors associated with in‐hospital mortality. In the derivation cohort, 956 patients were discharged alive, and 745 patients (43.8%) died during hospitalization. Among 29 candidate variables, 12 were independently associated with in‐hospital mortality and were applied as components of the risk model, including age, sex, body mass index, fulminant myocarditis aetiology, cardiac arrest in hospital, baseline veno‐arterial extracorporeal membrane oxygenation use, mean arterial pressure, lactate, lactate dehydrogenase, total bilirubin, creatinine, and albumin levels. The comparison of predicted and observed in‐hospital mortality according to the 7th quantiles using the J‐PVAD risk score showed good calibration. The area under the curve for the J‐PVAD risk score was 0.76 (95% confidence interval 0.73–0.78). In the validation cohort, the J‐PVAD risk score showed good calibration and discrimination ability.The J‐PVAD risk score can be calculated using variables easily obtained in routine clinical practice. It helps the accurate stratification of mortality risk and facilitates clinical decision‐making. [ABSTRACT FROM AUTHOR]

Background: Patients with severe respiratory failure due to COVID‐19 who are not under mechanical ventilation may develop severe hypoxemia when complicated with spontaneous pneumomediastinum (PM). These patients may be harmed by invasive ventilation. Alternatively, veno‐venous (V‐V) extracorporeal membrane oxygenation (ECMO) may be applied. We report on the efficacy of V‐V ECMO and invasive ventilation as initial advanced respiratory support in patients with COVID‐19 and acute respiratory failure due to spontaneous PM. Methods: This was a retrospective cohort study performed between March 2020 and January 2022. Enrolled patients had COVID‐19 and acute respiratory failure due to spontaneous PM and were not invasively ventilated. Patients were treated in the intensive care unit (ICU) with invasive ventilation (invasive ventilation group) or V‐V ECMO support (V‐V ECMO group) as the main therapeutic option. The primary outcomes were mortality and ICU discharge at 90 days after ICU admission. Results: Twenty‐two patients were included in this study (invasive ventilation group: 13 [59%]; V‐V ECMO group: 9 [41%]). The V‐V ECMO strategy was significantly associated with lower mortality (hazard ratio [HR] 0.33 [95% CI 0.12–0.97], p = 0.04). Five (38%) patients in the V‐V ECMO group were intubated and eight (89%) patients in the invasive ventilation group required V‐V ECMO support within 30 days from ICU admission. Three (33%) patients in the V‐V ECMO group were discharged from ICU within 90 days compared to one (8%) patient in the invasive ventilation group (HR 4.71 [95% CI 0.48–45.3], p = 0.18). Conclusions: Preliminary data suggest that V‐V ECMO without invasive ventilation may improve survival in COVID‐19‐related acute respiratory failure due to spontaneous PM. The study's retrospective design and limited sample size underscore the necessity for additional investigation and warrant caution. [ABSTRACT FROM AUTHOR]

The article discusses the need for new guidelines specifically focused on cardiac arrest in the peri-operative period. The 7th National Audit Project (NAP7) found that the incidence of peri-operative cardiac arrest in adults undergoing non-obstetric surgery is higher than previously estimated. The study also highlighted suboptimal care practices, such as the use of adrenaline, calcium, and bicarbonate, which may not be evidence-based. The article suggests that clear and concise guidelines would help improve the management of peri-operative cardiac arrest. Additionally, the article discusses the use of extracorporeal membrane oxygenation (ECMO) as a potential treatment for refractory cardiac arrest, but notes that its implementation is limited due to logistical complexities and lack of high-quality evidence. The authors argue that despite the challenges, ECMO should be considered in the guidelines for peri-operative cardiac arrest management. [Extracted from the article]

The article discusses the use of extracorporeal cardiopulmonary resuscitation (ECPR) as a potential intervention for patients with refractory cardiac arrest. ECPR involves draining blood from the body, oxygenating it, and then returning it to the arterial system, providing better oxygen delivery than conventional CPR. The article highlights the need for a proactive approach to implementing ECPR in the UK, as it is currently underutilized. The article also discusses the selection criteria for ECPR and the challenges in implementing ECPR services. The authors emphasize the importance of developing institutional expertise and ensuring equitable access to ECPR services across the UK. [Extracted from the article]

Background: Extracorporeal membrane oxygenation (ECMO) can be a life‐saving treatment for patients requiring advanced cardiopulmonary support. Several ECMO centres offer interhospital transport (ECMO IHT) services that involve establishing ECMO teams to initiate ECMO at referring hospitals and then transfer patients to ECMO centres. ECMO IHT is often high risk and complex. Understanding the experience of transport team members is crucial to ensure patient safety and promote quality improvement. Aim: To explore the experiences of transport teams performing ECMO IHT. Study Design: A descriptive qualitative methodology was adopted. Results: Thirteen health care professionals who have performed ECMO IHT at a general hospital in China agreed to be interviewed and enrolled in this study. Two investigators conducted face‐to‐face individual interviews in September–November 2022. All interviews were audio‐recorded, transcribed verbatim and analysed using inductive thematic analysis. Three main themes and nine sub‐themes were developed: (1) practicing with good organizational management (conducting training programs, cultivating the spirit of good teamwork and developing a standardized transport procedure), (2) dedicated to ensuring patient safety (adequate preparation and regular checking to reduce risk, accurate evaluation to avoid futility and maintaining communication to increase safety) and (3) having confidence despite being uneasy (feeling stressed is common, facing insecurity in transport settings and gaining confidence through practice). Conclusions: Health care professionals must adequately prepare and assess ECMO IHT to ensure patient safety. Supportive measures should be taken to ensure team members' health and improve patient safety. Good communication and teamwork could improve this challenging task. Further research is required for training programs and establishing standardized transport procedures. Relevance to Clinical Practice: This study presents multi‐professional perspectives on the experience of performing ECMO IHT to help management identify what needs to be further developed. With the increasing number of ECMO IHT, promoting its standardization is warranted. [ABSTRACT FROM AUTHOR]

Background: We aim to describe our experience with bronchoscopy to diagnose and relieve tracheobronchial obstruction in anticipation of decannulation in children on extracorporeal membrane oxygenation (ECMO) support. Methods: A retrospective cohort study of children on ECMO between 1/2018 and 12/2022. Results: A total of 107 children required ECMO support during the study period for cardiac (n = 48, 45%), pulmonary (n = 38, 36%), or cardiopulmonary dysfunction (n = 21, 20%). Thirty‐seven (35%) patients underwent 99 bronchoscopies while on ECMO. Most (76%, n = 75) experienced no improvement or worsening of chest radiography 24 hours following bronchoscopy. Clinical improvement in tidal volumes 48 hours after the first bronchoscopy was noted in 13/25 patients with available data (p = 0.05). Adverse events were seen in 18 (49%) patients who underwent bronchoscopy, including pneumothorax (n = 8, 22%), pneumonia (n = 7, 19%), pulmonary hemorrhage (n = 6, 16%), and sepsis (n = 5, 14%). ECMO courses were longer (25.4 ± 37.2 vs 6.1 ± 8.8 days, p < 0.0001) and more likely to be complicated by pneumonia (p = 0.0004) and sepsis (p = 0.047) in patients who underwent bronchoscopy compared with those who did not. Adverse events following bronchoscopy were associated with the number of bronchoscopies (p = 0.0003) and the presence of obstructive materials but not with the type of bronchoscopy or indication for ECMO. Mortality rates were similar between patients who underwent bronchoscopy and those who did not. Conclusion: Children requiring bronchoscopy represent a subset of the sickest children on ECMO. Bronchoscopy may provide benefit in children with persistent cardiopulmonary failure who could not otherwise be decannulated. Adverse events are associated with the number of bronchoscopies and the presence of obstructive material. Level of Evidence: 4 Laryngoscope, 134:4134–4140, 2024 [ABSTRACT FROM AUTHOR]

Background Methods Results Cardiac arrest is associated with high mortality rates and severe neurological impairments. One of the underlying mechanisms is global ischemia‐reperfusion injury of the body, particularly the brain. Strategies to mitigate this may thus improve favorable neurological outcomes. The use of extracorporeal cardiopulmonary membrane oxygenation (ECMO) during CA has been shown to improve survival, but available systems are vastly unable to deliver goal‐oriented resuscitation to control patient's individual physical and chemical needs during reperfusion. Recently, controlled automated reperfusion of the whoLe body (CARL), a pulsatile ECMO with arterial blood‐gas analysis, has been introduced to deliver goal‐directed reperfusion therapy during the post‐arrest phase.This review focuses on the device profile and use of CARL. Specifically, we reviewed the published literature to summarize data regarding its technical features and potential benefits in ECPR.Peri‐arrest, mitigating severe IRI with ECMO, might be the next step toward augmenting survival rates and neurological recovery. To this end, CARL is a promising extracorporeal oxygenation device that improves the early reperfusion phase after resuscitation. [ABSTRACT FROM AUTHOR]

The article discusses the need for a standardized circuit diagram for continuous renal replacement therapy (CRRT). The authors argue that a homogenized set of CRRT model diagrams, similar to a circuit diagram, is necessary to help users understand the basic principles and operating characteristics of different CRRT techniques. The article describes the design process for creating these diagrams, which include icons, symbols, lines, and letters to illustrate the working principles of various CRRT modalities. The authors believe that these standardized diagrams will facilitate teaching, training, and academic communication in the field of CRRT. [Extracted from the article]

Background Methods Results Conclusion The increasing complexity of congenital cardiac surgery has led to greater utilization of extracorporeal membrane oxygenation (ECMO) support for children post‐surgery. This study aims to identify risk factors for mortality and brain injury in pediatric patients requiring post‐cardiotomy ECMO and to evaluate their neurological outcomes.This retrospective study includes pediatric patients with congenital heart diseases who required ECMO after surgery. Risk factors for in‐hospital mortality and brain injury were assessed. Neurodevelopmental status was determined using the Pediatric Cerebral Performance Category (PCPC) Scale at discharge and during follow‐up.Between October 2014 and May 2021, 2651 pediatric patients underwent cardiac surgery, with 90 (3.4%) requiring ECMO. The mean age was 0.6 years, ranging from 1 day to 13 years and 7 months. ECMO was implemented for 45 patients due to CPB weaning failure (NW‐CPB), 24 due to postoperative low‐cardiac output syndrome (LCOS), and 21 for extracorporeal cardiopulmonary resuscitation (E‐CPR). ECMO weaning was achieved in 73 patients (81%), with an overall mortality rate of 36%. Pre‐implant lactate levels (OR: 1.13, 95% CI: 1.03–1.25; p = 0.009) and peak bilirubin levels (OR: 1.04, 95% CI: 0.87–1.24; p = 0.69) were risk factors for in‐hospital mortality. Survival rates were 79% for LCOS, 60% for NW‐CPB, and 48% for E‐CPR. Brain injury incidence was 33%, with E‐CPR being a significant risk factor (p = 0.006) and NW‐CPB being protective (p = 0.001). Follow‐up in November 2023 showed significant improvement in neurodevelopmental status (p < 0.001).Elevated pre‐implant lactate and elevated bilirubin levels during ECMO are major risk factors for mortality. E‐CPR is the primary risk factor for brain injury. Follow‐up revealed significant improvements in neurodevelopmental outcomes. [ABSTRACT FROM AUTHOR]

Aims Methods and results Conclusions Among patients with cardiogenic shock, immediate initiation of extracorporeal membrane oxygenation (ECMO) did not demonstrate any benefit at 30 days. The present study evaluated 1‐year clinical outcomes of the Extracorporeal Membrane Oxygenation in the therapy of Cardiogenic Shock (ECMO‐CS) trial.The ECMO‐CS trial randomized 117 patients with severe or rapidly progressing cardiogenic shock to immediate initiation of ECMO or early conservative strategy. The primary endpoint for this analysis was 1‐year all‐cause mortality. Secondary endpoints included a composite of death, resuscitated cardiac arrest or implantation of another mechanical circulatory support device, duration of mechanical ventilation, and the length of intensive care unit (ICU) and hospital stays. In addition, an unplanned post‐hoc subgroup analysis was performed. At 1 year, all‐cause death occurred in 40 of 58 (69.0%) patients in the ECMO arm and in 40 of 59 (67.8%) in the early conservative arm (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.66–1.58; p = 0.93). The composite endpoint occurred in 43 (74.1%) patients in the ECMO group and in 47 (79.7%) patients in the early conservative group (HR 0.83, 95% CI 0.55–1.25; p = 0.29). The durations of mechanical ventilation, ICU stay and hospital stay were comparable between groups. Significant interaction with treatment strategy and 1‐year mortality was observed in subgroups according to baseline mean arterial pressure (MAP) indicating lower mortality in the subgroup with low baseline MAP (<63 mmHg: HR 0.58, 95% CI 0.29–1.16; pinteraction = 0.017).Among patients with severe or rapidly progressing cardiogenic shock, immediate initiation of ECMO did not improve clinical outcomes at 1 year compared to the early conservative strategy. However, immediate ECMO initiation might be beneficial in patients with advanced haemodynamic compromise. [ABSTRACT FROM AUTHOR]

The article describes the case of a seven-day old neonate with prenatal diagnosis of congenital pulmonary airway malformation and was diagnosed with anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA), a rate congenital heart disease. It describes the patient's echocardiographic results and cites possible complications from extracorporeal membrane exygenation (ECMO). It refers to coronary reimplantation as the most common surgical strategy for ARCAPA.

Background: Extracorporeal membrane oxygenation (ECMO) is used in critically ill children with cardiac and/or respiratory failure. Use is increasing in children with high‐risk comorbidities. Reasons children do not survive ECMO are poorly described. Aims: Describe characteristics and cause of death, compare mortality in children with high‐risk comorbidities, evaluate mortality trends over a decade. Method: All children <18 years old who received ECMO at this institution from 1 January 2011 to 31 December 2020 were described and categorised by outcome: died on or <48 h post‐ECMO, died ≥48 h post‐ECMO, survived to hospital discharge. Children who did not survive ECMO (DNSE) were categorised to: ECMO withdrawal for irrecoverable original condition, withdrawal for poor prognosis neurological condition, brain death, withdrawal for poor prognosis with multiple complex conditions, and unsupportable. Poison regression was used to analyse survival trends. Results: Four hundred twenty‐eight children received ECMO, 19% DNSE, 14% died ≥48 h post‐ECMO and 67% survived. ECMO was electively withdrawn for irrecoverable original condition (39%), poor prognosis for neurological condition (32%) or multiple complex conditions (18%). One hundred twenty‐two children had ≥1 high‐risk comorbidity. Children with genetic syndromes (58%), risk‐adjusted congenital heart surgery score‐1 ≥4 (53%), primary immunodeficiency (50%) had lower hospital survival. No children with malignancy/bone marrow transplant survived to hospital discharge. Overall hospital survival was 67%, with no significant change during the study period (P‐trend = 0.99). Conclusion: Children who DNSE have therapy electively withdrawn for irrecoverable disease or poor prognosis. Children with high‐risk comorbidities have a reasonable chance of survival. This study informs clinicians ECMO may be a therapeutic option. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is a type of circulatory life support for patients with severe lung failure. The use of ECMO has increased worldwide since the pandemic of H1N1 in 2009 and more recently SARS‐CoV‐2 in 2020 both of which caused severe respiratory failure. ECMO patients experience both increased risk of bleeding and thrombosis. This is due to the pathological insult that damages the lungs, the ECMO circuit, coagulopathy, inflammation and anticoagulation. ECMO presents unique demands on the coagulation laboratory both in tests required to manage the patients and result interpretation. This is a personal opinion of 20 years ECMO experience as a clinical scientist and a short current review of the literature. It will focus on the laboratory coagulation tests used to manage ECMO patients, including different anticoagulants used, testing frequency and interpretation of the results. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) is widely used for children treated for refractory respiratory failures or refractory cardiogenic shock. Its duration depends on organ functions recovery. Weaning is decided using macro‐circulatory tools, but microcirculation is not well evaluated. Sidestream dark‐field video imaging is used to assess the perfusion of the sublingual microvascular vessels. The aim of this study was to assess the predictive value of microcirculatory indices in ECMO weaning. Methods: This prospective monocentric study examined pediatric patients at Trousseau Hospital between March 2017 and December 2020. The study included all patients from 35 weeks of gestational age to 18 years old who were treated with ECMO. Children were divided into two groups: one with stability after weaning and the other with instability after weaning. We collected clinical and biological data, ventilation parameters, extracorporeal membrane oxygenation parameters, and drugs used at admission and after the weaning test. Microcirculations videos were taken after weaning trials with echocardiography and blood gas monitoring. Results: The study included 30 patients with a median age of 29 days (range: 1–770 days) at admission, including 18 patients who received venoarterial ECMO (60%). There were 19 children in the stability group and 11 in the instability group. Macrocirculatory and microcirculatory indices showed no differences between groups. The microvascular flow index was subnormal in both groups (2.3 (1.8–2.4) and 2.3 (2.3–2.6), respectively; p = 0.24). The microvascular indices were similar between cases of venovenous and venoarterial ECMO and between age groups. Conclusion: Microcirculation monitoring at the weaning phase did not predict the failure of ECMO weaning. [ABSTRACT FROM AUTHOR]

Background: The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population. Methods and Results: INTERMACS 1 LVAD recipients from five U.S. centers were included. In‐hospital and one‐year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non‐ECMO patients by propensity‐weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one‐year outcomes. One hundred and twenty‐seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06–9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non‐ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non‐ECMO: 4.9%, p = 0.006). Among the study cohort, one‐year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients. Conclusions: Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one‐year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices. [ABSTRACT FROM AUTHOR]

Background: The use of ECMO as a bridge to heart transplantation has been growing rapidly in all heart transplant recipients since the implementation of the new UNOS allocation policy; however, the impact on adult congenital heart disease (ACHD) patients is not known. Methods: We analyzed the UNOS data (2015–2021) for ACHD patients supported with extracorporeal membrane oxygenation (ECMO) during the waitlist, before and after October 2018, to assess the impact on the waitlist and posttransplant outcomes. We compared the characteristics and outcomes of ACHD patients with or without ECMO use during the waitlist and pre‐ and postpolicy changes. Results: A total of 23 821 patients underwent heart transplantation, and only 918 (4%) had ACHD. Out of all ACHD patients undergoing heart transplants, 6% of patients in the prepolicy era and 7.6% in the postpolicy era were on ECMO at the time of listing. Those on ECMO were younger and sicker compared to the rest of the ACHD cohort. Those on ECMO had similar profiles pre‐ and postpolicy change; however, there was a very significant decrease in the waitlist time [136 days (IQR 29–384) vs. 38 days (IQR 11–108), p = 0.01]. There was no difference in waitlist mortality; however, competing risk analyses showed a higher likelihood of transplantation (51% vs. 29%) and a lower likelihood of death or deterioration (31% vs. 42%) postpolicy change. Long‐term outcomes posttransplant for those supported with ECMO compared to the non‐ECMO cohort are similar for ACHD patients, although there was higher attrition in the first year for the ECMO cohort. Conclusion: The new allocation policy has resulted in shorter waitlist times and a higher likelihood of transplantation for ACHD patients supported by ECMO. However, the appropriate use of ECMO and the underuse of durable circulatory support devices in this population need further exploration. [ABSTRACT FROM AUTHOR]

Introduction: To facilitate the implementation of controlled donation after circulatory death (cDCD) programs even in hospitals not equipped with a local extracorporeal membrane oxygenation (ECMO) team, some countries have launched a local cDCD network with an ECMO mobile team for normothermic regional perfusion (NRP). In the Tuscany region, in 2021, the Regional Transplant Authority launched a cDCD program to make the cDCD pathway feasible even in peripheral hospitals with NRP mobile teams, which were "converted" existing ECMO mobile teams, composed of highly skilled and experienced personnel. Methods: We describe the Tuscany cDCD program, (2021–2023), for cDCD from peripheral hospitals with NRP mobile teams. Results: Twenty‐six cDCDs (26/40, 65%) came from peripheral hospitals. Following the launch of the cDCD program, cDCDs from peripheral hospitals increased, from 33% (2021) to 75% (2022 and 2023) of the overall cDCDs. The mean age was 63 years, with older donors (>75 years) in half the cases. The median warm ischemia time was 45 min (20 min are required by the Italian law for death certification), ranging from 35 to 59 min. Among the 20 livers retrieved and 18 kidneys retrieved, 16 livers, and 11 kidneys (single kidney transplantation) were transplanted, after ex vivo reperfusion, respectively. Conclusions: The use of NRP mobile teams proved to be feasible and safe in the management of cDCD in peripheral hospitals. No complications were reported with NRP despite the advanced age of most cDCDs. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology. Methods: Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first‐time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine–Gray regression. Results: A total of 16 143 patients were identified of whom 7.0% (n = 1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p < 0.01) and were more likely to undergo transplantation (75.3% vs. 70.3%, p < 0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p < 0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p < 0.01) and hypertrophic CMP (SHR: 9.78, p < 0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p < 0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p = 0.03). Conclusions: The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision‐making surrounding candidacy for cannulation and prognostic evaluation. [ABSTRACT FROM AUTHOR]

To date, there have been no reports of recording epicardial electrograms at the onset of spontaneous ventricular fibrillation (VF) in patients with Brugada syndrome (BrS). In the case of BrS, unipolar and bipolar electrogram recording on the right ventricular epicardium revealed that dispersion of repolarization with delayed potential was associated with spontaneous occurrence of VF. Phase 2 reentry associated with shortening and dispersion of action potential could have been recorded for the first time in BrS. Epicardial unipolar mapping can guide accurate and appropriate ablation for the elimination of arrhythmia substrate in J wave syndrome. [ABSTRACT FROM AUTHOR]

Aims: Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) with profound left ventricular (LV) failure is associated with inadequate LV emptying. To unload the LV, VA‐ECMO can be combined with Impella CP (ECMELLA). We hypothesized that ECMELLA improves cardiac energetics compared with VA‐ECMO in a porcine model of cardiogenic shock (CS). Methods and results: Land‐race pigs (weight 70 kg) were instrumented, including a LV conductance catheter and a carotid artery Doppler flow probe. CS was induced with embolization in the left main coronary artery. CS was defined as reduction of ≥50% in cardiac output or mixed oxygen saturation (SvO2) or a SvO2 < 30%. At CS VA‐ECMO was initiated and embolization was continued until arterial pulse pressure was <10 mmHg. At this point, Impella CP was placed in the ECMELLA arm. Support was maintained for 4 h. CS was induced in 15 pigs (VA‐ECMO n = 7, ECMELLA n = 8). At time of CS MAP was <45 mmHg in both groups, with no difference at 4 h (VA‐ECMO 64 mmHg ± 11 vs. ECMELLA 55 mmHg ± 21, P = 0.08). Carotid blood flow and arterial lactate increased from CS and was similar in VA‐ECMO and ECMELLA [239 mL/min ± 97 vs. 213 mL/min ± 133 (P = 0.6) and 5.2 ± 3.3 vs. 4.2 ± 2.9 mmol/ (P = 0.5)]. Pressure‐volume area (PVA) was significantly higher with VA‐ECMO compared with ECMELLA (9567 ± 1733 vs. 6921 ± 5036 mmHg × mL/min × 10−3, P = 0.014). Total diureses was found to be lower in VA‐ECMO compared with ECMELLA [248 mL (179–930) vs. 506 mL (418–2190); P = 0.005]. Conclusions: In a porcine model of CS, we found lower PVA, with the ECMELLA configuration compared with VA‐ECMO, indicating better cardiac energetics without compromising systemic perfusion. [ABSTRACT FROM AUTHOR]

Aims: Drug‐refractory electrical storm (ES) is a life‐threatening medical emergency. We describe the use of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) in drug‐refractory ES without a reversible trigger, for which specific guideline recommendations are still lacking. Methods and results: Retrospective observational study in four Iberian centres on the indications, treatment, complications, and outcome of drug‐refractory ES not associated with acute coronary syndromes, decompensated heart failure, drug toxicity, electrolyte disturbances, endocrine emergencies, concomitant acute illness with fever, or poor compliance with anti‐arrhythmic drugs, requiring VA‐ECMO for circulatory support. Thirty‐four (6%) out of 552 patients with VA‐ECMO for cardiogenic shock were included [71% men; 57 (44–62) years], 65% underwent cardiopulmonary resuscitation before VA‐ECMO implantation, and 26% during cannulation. Left ventricular unloading during VA‐ECMO was used in 8 (24%) patients: 3 (9%) with intraaortic balloon pump, 3 (9%) with LV vent, and 2 (6%) with Impella. Thirty (88%) had structural heart disease and 8 (24%) had an implantable cardioverter‐defibrillator. The drug‐refractory ES was mostly due to monomorphic ventricular tachycardia (VT) and ventricular fibrillation (VF) (59%), isolated monomorphic VT (26%), polymorphic VT (9%), or VF (6%). Thirty‐one (91%) required deep sedation, 44% overdrive pacing, 36% catheter ablation, and 26% acute autonomic modulation. The main complications were nosocomial infection (47%), bleeding (24%), and limb ischaemia (21%). Eighteen (53%) were weaned from VA‐ECMO, and 29% had heart transplantation. Twenty‐seven (79%) survived to hospital discharge (48 (33–82) days). Non‐survivors were older [62 (58–67) vs. 54 (43–58); P < 0.01] and had a higher first rhythm disorder‐to‐ECMO interval [0 (0–2) vs. 2 (1‐11) days; P = 0.02]. Seven (20%) had rehospitalization during follow‐up [29 (12–48) months], with ES recurrence in 6%. Conclusions: VA‐ECMO bridged drug‐refractory ES without a reversible trigger with a high success rate. This required prolonged hospital stays and coordination between the ECMO centre, the electrophysiology laboratory, and the heart transplant programme. [ABSTRACT FROM AUTHOR]

Aims: Acute myocardial infarction (AMI) resulting from unprotected left main coronary artery (LMCA) occlusion and subtotal occlusion is a life‐threatening condition. Although AMI management has improved in the past two decades, there is limited information on recent trends in patient characteristics, management, and outcomes for acute unprotected LMCA‐related AMI. This study aims to assess such trends over a 12 year period. Methods and results: This retrospective multicentre study includes patients with unprotected LMCA occlusion/subtotal occlusion admitted to three tertiary hospitals between 2008 and 2020. The patients were divided into two groups based on the chronology of presentation: a 'past group' (January 2008 to December 2014) and a 'contemporary group' (January 2015 to December 2020). The study compares clinical characteristics, management approaches, and outcomes between the two groups. The study includes 128 patients, with 51 (40%) in the 'past group' and 77 (60%) in the 'contemporary group'. Baseline risk factors did not show statistically significant differences between the two groups, except for hypertension (49% vs. 74%; P = 0.005). Chest pain was more frequent in the 'past group' (98% vs. 89%; P = 0.014), and a trend towards more cardiac arrests was observed in the 'contemporary group' (18% vs. 31%; P = 0.087). Revascularization type did not differ significantly (P = 0.419), but manual thrombectomy was less frequently used (41% vs. 23%; P = 0.032) and stent implantation showed a trend towards higher rates (66% vs. 78%; P = 0.150) in the 'contemporary cohort'. There was a gradual shift from bare‐metal to drug‐eluting stents, with a significantly higher percentage of ticagrelor/prasugrel loading in the 'contemporary cohort' (5% vs. 79%; P < 0.001). The use of mechanical circulatory support (MCS), although not statistically significant, was higher among patients in the 'past group' (67% vs. 51%; P = 0.073). The type of MCS differed significantly between groups, with a decrease in intra‐aortic balloon pump use (67% vs. 42%; P = 0.005) and an increase in veno‐arterial extracorporeal membrane oxygenation (4% vs. 22%; P = 0.005) and Impella system (0% vs. 3%) over time. Survival analysis showed no significant differences (P = 0.599; log‐rank test) in all‐cause mortality between the different time groups, with the long‐term survival rate being approximately 30%. Conclusions: In our real‐world population, despite the progressive use of newer drugs and more advanced devices over time, patients with unprotected LMCA occlusion/subtotal occlusion remain a subpopulation with poor prognosis. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Cardiopulmonary resuscitation (CPR) is the cornerstone intervention for cardiac arrest, with extracorporeal CPR (ECPR) demonstrating enhanced survival and neurologic outcomes in in‐hospital cardiac arrest. This study explores the time interval between CPR initiation and the onset of extracorporeal membrane oxygenation (ECMO) in ECPR recipients, investigating its impact on survival outcomes.This retrospective analysis included 1950 adults who received CPR at a single medical center between March 2019 and April 2023. Data from 198 adult patients who had ECMO inserted during CPR were analyzed. The interval from CPR initiation to ECMO initiation was quantified and categorized as ≤20, 20–40, and >40 min. Cox regression analysis assessed associations between CPR‐to‐ECMO time and short‐ and long‐term mortalities.Among the 198 patients who underwent ECPR, 116 (58.6%) experienced 30‐day mortality. Initiation of ECMO within 20 min occurred in 46 (23.2%), whereas 74 (37.4%) had ECMO initiated after 40 min. Cox regression revealed a significant association between time from CPR to ECMO initiation and 30‐day mortality (adjusted hazard ratio [HR]: 2.20 in >40 min, HR: 2.63 in 20–40 min, p = 0.006) and 6‐month mortality (HR: 1.81, in >40 min, HR: 1.99 in 20–40 min, p = 0.021).This study revealed that, in ECPR recipients, a shorter duration between CPR initiation and ECMO flow commencement is associated with improved short‐ and long‐term patient prognoses. These findings emphasize the critical role of timely ECMO application in optimizing outcomes for patients undergoing ECPR. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary bypass device commonly used to treat cardiac arrest in children. The American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care recommend using amiodarone as a first‐line agent to treat ventricular arrhythmias in children with cardiac arrest. However, there are no dosing recommendations for amiodarone to treat ventricular arrhythmias in pediatric patients on ECMO. Amiodarone has a high propensity for adsorption to the ECMO components due to its physicochemical properties leading to altered pharmacokinetics (PK) in ECMO patients. The change in amiodarone PK due to interaction with ECMO components may result in a difference in optimal dosing in patients on ECMO when compared with non‐ECMO patients. To address this clinical knowledge gap, a physiologically‐based pharmacokinetic model of amiodarone was developed in adults and scaled to children, followed by the addition of an ECMO compartment. The pediatric model included ontogeny functions of cytochrome P450 (CYP450) enzyme maturation across various age groups. The ECMO compartment was parameterized using the adsorption data of amiodarone obtained from ex vivo studies. Model predictions captured observed concentrations of amiodarone in pediatric patients with ECMO well with an average fold error between 0.5 and 2. Model simulations support an amiodarone intravenous (i.v) bolus dose of 22 mg/kg (neonates), 13 mg/kg (infants), 8 mg/kg (children), and 6 mg/kg (adolescents). This PBPK modeling approach can be applied to explore the dosing of other drugs used in children on ECMO. [ABSTRACT FROM AUTHOR]

Cardiogenic shock (CS) is a severe complication of peripartum cardiomyopathy (PPCM). Patients with deteriorating CS often require temporary mechanical circulatory support. In PPCM, this can be used as a bridge to postpartum recovery or bridge to decision. The outcomes are unclear, especially if prolonged utilization is required. We present a case series of three patients with PPCM in deteriorating CS who were successfully supported with a ventricular assist device or veno‐arterial extracorporeal membrane oxygenation as a bridge to postpartum recovery. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) is increasingly utilized in pediatric patients. Failure to recognize membrane oxygenator failure can lead to critical complications due to rapid deterioration of membrane oxygenator function. Therefore, identifying the predictors for membrane oxygenator exchange is crucial. However, risk factors for membrane oxygenator exchange in pediatric V‐A ECMO remain unclear; therefore, this study aimed to evaluate these risk factors.This retrospective cohort study enrolled all pediatric patients aged <18 years who received V‐A ECMO between August 2018 and July 2023 at a tertiary‐care pediatric hospital in Japan. The Cox proportional hazards model was used to evaluate the predictors of membrane oxygenator failure within 72 h after initiation.During the study period, membrane oxygenator failure occurred in 18/55 (32.7%) children within 72 h; membrane oxygenator failure within 72 h occurred in 4/29 (13.8%) and 14/26 (53.8%) in the groups with ratio of blood flow divided by the blood flow limit of the membrane oxygenator (B/L) of <0.5 and ≥0.5, respectively (adjusted hazards ratio, 4.97 [95% confidence interval, 1.33–18.5]; p = 0.017). After adjusting for delta pressure of the oxygenator, an increase in body weight and aspartate aminotransferase levels were associated with an increase in early membrane oxygenator failure.This retrospective study demonstrated that a B/L ratio >0.5, an increase in body weight, and elevated aspartate aminotransferase were independent risk factors for early membrane oxygenator failure in pediatric V‐A ECMO. However, a prospective multicenter study with an appropriate sample size is warranted to mitigate potential bias, and enhance generalizability for further investigation of the association between a B/L ratio and early membrane oxygenator failure. [ABSTRACT FROM AUTHOR]

Objectives Methods Results Conclusions Post‐cardiotomy extracorporeal life support (ECLS) cannulation might occur in a general post‐operative ward due to emergent conditions. Its characteristics have been poorly reported and investigated This study investigates the characteristics and outcomes of adult patients receiving ECLS cannulation in a general post‐operative cardiac ward.The Post‐cardiotomy Extracorporeal Life Support (PELS) is a retrospective (2000–2020), multicenter (34 centers), observational study including adult patients who required ECLS for post‐cardiotomy shock. This PELS sub‐analysis analyzed patients´ characteristics, in‐hospital outcomes, and long‐term survival in patients cannulated for veno‐arterial ECLS in the general ward, and further compared in‐hospital survivors and non‐survivors.The PELS study included 2058 patients of whom 39 (1.9%) were cannulated in the general ward. Most patients underwent isolated coronary bypass grafting (CABG, n = 15, 38.5%) or isolated non‐CABG operations (n = 20, 51.3%). The main indications to initiate ECLS included cardiac arrest (n = 17, 44.7%) and cardiogenic shock (n = 14, 35.9%). ECLS cannulation occurred after a median time of 4 (2–7) days post‐operatively. Most patients' courses were complicated by acute kidney injury (n = 23, 59%), arrhythmias (n = 19, 48.7%), and postoperative bleeding (n = 20, 51.3%). In‐hospital mortality was 84.6% (n = 33) with persistent heart failure (n = 11, 28.2%) as the most common cause of death. No peculiar differences were observed between in‐hospital survivors and nonsurvivors.This study demonstrates that ECLS cannulation due to post‐cardiotomy emergent adverse events in the general ward is rare, mainly occurring in preoperative low‐risk patients and after a postoperative cardiac arrest. High complication rates and low in‐hospital survival require further investigations to identify patients at risk for such a complication, optimize resources, enhance intervention, and improve outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Echocardiography is considered essential during cannulation placement and manipulations. Literature evaluating transthoracic echocardiography (TTE) usage during pediatric VV‐ECMO is scant. The purpose of this study is to describe the use of echocardiography during VV‐ECMO at a large, quaternary children's hospital. Methods: A retrospective, single‐year cohort study was performed of pediatric patients on VV‐ECMO via dual‐lumen cannula at our institution from January 2019 through December 2019. For each echocardiogram, final cannula component (re‐infusion port (ReP), distal tip, proximal port and distal port) positions were evaluated by one echocardiographer. For TTEs with ReP in the right atrium, two echocardiographers independently evaluated ReP direction using 2‐point (Yes/No) and 4‐point scales, which were semi‐quantitative protocols using color Doppler images to estimate ReP jet direction to the tricuspid valve. Cohen's kappa or weighted kappa was used to measure interrater agreement. Results: During study period, 11 patients (64% male) received VV‐ECMO with 49 TTEs and one transesophageal echocardiogram performed. The median patient age was 4.3 years [IQR: 1.1–11.5] and median VV‐ECMO run time of 192 h [90–349]. The median time between TTEs on VV‐ECMO was 34 h [8.3–65]. Most common position for the ReP was the right atrium (n = 33, 67%), and ReP location was not identified in five TTEs (10%). For ReP flow direction, echocardiographers agreed on 82% of TTEs using 2‐point evaluation. There was only moderate agreement between echocardiographers on the 2‐point and 4‐point assessments (k =.54, kw =.46 respectively). Conclusions: TTE is the predominant cardiac ultrasound modality used during VV‐ECMO for pediatric respiratory failure. Subjective evaluation of VV‐ECMO ReP jet direction in the right atrium is challenging, regardless of assessment method. [ABSTRACT FROM AUTHOR]

This article discusses a case study of a 25-year-old male with sickle cell disease (SCD) who developed acute chest syndrome (ACS) and severe acute respiratory distress syndrome (ARDS). The patient was successfully treated with veno-venous extracorporeal membrane oxygenation (V-V ECMO). ACS is a common cause of ICU admission for patients with SCD, and those requiring invasive mechanical ventilation for more than 96 hours have a higher risk of mortality. The use of ECMO in patients with ACS is limited, but this case suggests that it may be a viable treatment option for severe cases. However, further research is needed to optimize ECMO candidacy and care for patients with ACS. [Extracted from the article]

Background: Although acute kidney injury (AKI) has been established as an independent risk factor for in‐hospital mortality for patients on veno‐arterial (V‐A) extracorporeal membranous oxygenation (ECMO), the impact of Kidney Disease Improving Global Outcomes (KDIGO) stages of AKI has yet to be elucidated as a risk factor. Methods: We conducted a retrospective analysis of patient outcomes based on KDIGO stages of AKI at a single institution. The analysis was a cohort of 179 patients; 66 without AKI, 19 with stage 1 AKI, 18 with stage 2 AKI, and 76 with stage 3 AKI. Results: Every 1‐year increase in age was associated with 4% increased odds of mortality at 30 days (95% confidence interval [CI] 1.01, 1.07; p = 0.004). The presence of AKI at any stage was associated with 59% increased odds of 30‐day mortality (95% CI 0.81, 3.10; p = 0.176). The presence of stage 1 AKI was associated with a 5% decreased odds of 30‐day mortality (95% CI 0.32, 2.89). The presence of stage 2 AKI (odds ratio [OR] 2.29, 95% CI 0.69, 7.55; p = 0.173) and stage 3 AKI (OR 1.68, 95% CI 0.81, 3.46; p = 0.164) was associated with increased odds of 30‐day mortality. Conclusion: Based on our single‐center study, higher KDIGO stages of AKI likely have increased odds of mortality at 30 days. Larger studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: Using extracorporeal membrane oxygenation (ECMO) in paediatric and neonatal intensive care units (PICU/NICU) creates ethical challenges and carries a high risk for moral distress, burn out and team conflicts. Aim: The study aimed to gain a more comprehensive understanding of the underlying factors affecting moral distress when using ECMO for infants and children by examining the attitudes of ECMO nurses. Methods: Four focus groups discussions were conducted with 21 critical care nurses working in a Swiss University Children's Hospital. Purposive sampling was adopted to identify research participants. The data were analysed using reflexive thematic analysis. Results: Unlike "miracle machine" stories in online media reports, specialized nurses working in PICU/NICU expressed both their hopes and fears towards this technology. Their accounts also contained references to events and factors that triggered experiences of moral distress: the unspeakable nature of the death of a child or infant; the seemingly lack of honest and transparent communication with parents; the apparent loss of situational awareness among doctors; the perceived lack of recognition for the role of nurses and the variability in end-of-life decision-making; the length of time it takes doctors to take important treatment decisions; and the resource intensity of an ECMO treatment. Conclusion: The creation of a multidisciplinary moral community with transparent information among all involved health care professionals and the definition of clear treatment goals as well as the implementation of paediatric palliative care for all paediatric ECMO patients should become a priority if we want to alleviate situations of moral distress. Relevance for Clinical Practice: The creation of a multidisciplinary moral community, clear treatment goals and the implementation of palliative care for all paediatric ECMO patients are crucial to alleviate situations of moral distress for nurses, and thus to improve provider well-being and the quality of patient care in PICU/NICU. [ABSTRACT FROM AUTHOR]

Background: Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. Aim: To describe our single‐center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. Methods: Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. Results: Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild‐to‐moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake‐up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). Conclusions: Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) support of critically ill pediatric patients is associated with increased risk of thromboembolic events, and unfractionated heparin is used commonly for anticoagulation. Given reports of acquired antithrombin (AT) deficiency in this patient population and associated concern for heparin resistance, AT activity measurement and off‐label AT replacement have become common in pediatric ECMO centers despite limited optimal dosing regimens. We conducted a retrospective cohort study of pediatric ECMO patients (0 to <18 years) at a single academic center to characterize the pharmacokinetics (PK) of human plasma‐derived AT. We demonstrated that a two‐compartment turnover model appropriately described the PK of AT, and the parameter estimates for clearance, central volume, intercompartmental clearance, peripheral volume, and basal AT input under non‐ECMO conditions were 0.338 dL/h/70 kg, 38.5 dL/70 kg, 1.16 dL/h/70 kg, 40.0 dL/70 kg, and 30.4 units/h/70 kg, respectively. Also, ECMO could reduce bioavailable AT by 50% resulting in 2‐fold increase of clearance and volume of distribution. To prevent AT activity from falling below predetermined thresholds of 50% activity in neonates and 80% activity in older infants and children, we proposed potential replacement regimens for each age group, accompanied by therapeutic drug monitoring. [ABSTRACT FROM AUTHOR]

Normothermic regional perfusion (NRP) is a relatively new approach to procuring organs for transplantation. After circulatory death is declared, perfusion is restored to either the thoracoabdominal organs (in TA‐NRP) or abdominal organs alone (in A‐NRP) using extracorporeal membrane oxygenation. Simultaneously, surgeons clamp the cerebral arteries, causing a fatal brain injury. Critics claim that clamping the arteries is the proximate cause of death in violation of the dead donor rule and that the procedure is therefore unethical. We disagree. This account does not consider the myriad other factors that contribute to the death of the donor, including the presence of a fatal medical condition, the decision to withdraw life support, and the physician's actions in withdrawing life support and administering medication that may hasten death. Instead, we claim that physicians play a causative role in many of the events that lead to a patient's death and that these actions are often ethically and legally justified. We advance an "all things considered" view according to which TA‐NRP may be considered ethically acceptable insofar as it avoids suffering and respects the wishes of the patient to improve the lives of others through organ donation. We conclude with a series of critical questions related to the practice of NRP and call for the development of national consensus on this issue in the United States. [ABSTRACT FROM AUTHOR]

The article discusses the use of left atrial venting as a technique to unload the left ventricle in patients with cardiogenic shock undergoing extracorporeal life support (ECLS). Two recent trials, EARLY-UNLOAD and EVOLVE-ECMO, found no significant differences in 30-day mortality rates between early unloading through active left atrial venting and a rescue unloading strategy. The article acknowledges the challenges of interpreting the results due to sample size limitations and the complexity of intention-to-treat analysis. The authors suggest that further investigation is needed to determine the effectiveness and timing of left heart decompression techniques. The text also provides an overview of past and present mechanical circulatory support unloading trials in cardiogenic shock, highlighting the ongoing REMAP-ECMO and UNLOAD-ECMO trials that aim to determine the optimal timing of left heart decompression initiation. The article emphasizes the need for further research comparing different devices and timing of left heart decompression initiation, and suggests that decisions should be made on a case-by-case basis guided by local expertise and available strategies. [Extracted from the article]

In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second‐line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta‐blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor‐acetyl hydrolase or hereditary alpha‐tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Prone position ventilation (PPV) is recommended for patients with COVID‐19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V‐V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance.This study was a nationwide retrospective analysis of all COVID‐19 patients in Denmark from March 2020 – December 2021 with severe ARDS and need of V‐V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported.Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within‐patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course.Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance. [ABSTRACT FROM AUTHOR]

Background: As the pandemic progressed, the use of extracorporeal membrane oxygenation (ECMO) for COVID‐19‐related acute respiratory distress syndrome increased, and patient triage and transfer to ECMO centers became important to optimize patient outcomes. Our objectives are to identify predictors of patient transfer for veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) evaluation as well as to describe the outcomes of accepted patients. Methods: This is a single‐center, retrospective analysis of V‐V ECMO transfer requests for adult patients with known or suspected COVID‐19 and respiratory failure from March 2020 until March 2021. Data were collected prospectively during the triage process for transfer requests as part of clinical patient care at our institution. Results: Of 341 referred patients, 112 (33%) were accepted for transfer to our facility, whereas 229 (67%) patients were declined for transfer. The Classification and Regression Tree analysis showed that patients' high pressure during airway pressure release ventilation (APRV) and age were the variables most significantly associated with the decision to accept or decline patients for transfer. Conclusions: Our triage process enabled one‐third of referred patients to be transferred for evaluation, with nearly 70% of those patients ultimately receiving ECMO support. High ventilator settings on APRV and young age were associated with acceptance for transfer. Accepted patients also had a higher incidence of adjunctive therapies (proning and paralysis) prior to transfer request, less cardiac or renal dysfunction, and a shorter duration of mechanical ventilation. Further research is warranted to investigate the outcomes of nontransferred patients. [ABSTRACT FROM AUTHOR]

Introduction: For the Veterans Health Administration (VHA) to continue to perform complex cardiothoracic surgery, there must be an established pathway for providing urgent/emergent extracorporeal life support (ECLS). Partnership with a nearby tertiary care center with such expertise may be the most resource‐efficient way to provide ECLS services to patients in post‐cardiotomy cardiogenic shock or respiratory failure. The goal of this project was to assess the efficiency, safety, and outcomes of surgical patients who required transfer for perioperative ECLS from a single stand‐alone Veterans Affairs Medical Center (VAMC) to a separate ECLS center. Methods: Cohort consisted of all cardiothoracic surgery patients who experienced cardiogenic shock or refractory respiratory failure at the local VAMC requiring urgent or emergent institution of ECLS between 2019 and 2022. The primary outcomes are the safety and timeliness of transport. Results: Mean time from the initial shock call to arrival at the ECLS center was 2.8 h. There were no complications during transfer. Six patients (86%) survived to decannulation. Conclusion: These results suggest that complex cardiothoracic surgery can be performed within the VHA system and when there is an indication for ECLS, those services can be safely and effectively provided at an affiliated, properly equipped center. [ABSTRACT FROM AUTHOR]

Background: Methods for risk stratification of candidates for heart transplantation (HTx) supported by extracorporeal membrane oxygenation (ECMO) are limited. We evaluated the reliability of the APACHE IV score to identify the risk of mortality in this patient subset in a multicenter study. Methods: Between January 2010 and December 2022, 167 consecutive ECMO patients were bridged to HTx; they were divided into two groups, according to a cutoff value of APACHE IV score, obtained by receiver operating characteristic curve analysis for 90‐day mortality. Kaplan–Meier survival curves were plotted, and compared through the log‐Rank test. Cox regression model was used to estimate which factors were associated with survival. Results: The 90‐day mortality prediction of the APACHE IV score showed an area under the curve of 0.87 (95% CI: 0.80–0.94), with a cutoff value of 49 (specificity 91.7%–sensibility 69.6%). 125 patients (74.8%) showed an APACHE IV score value < 49 (Group A), and 42 (25.2%) ≥ 49 (Group B). 90‐day mortality was 11.2% in Group A and 76.2% in Group B (p < 0.01). Survival at 1 and 5 years was 85.5%, 77% versus 23.4%, 23.4% (p < 0.01) in Groups A and B. Mortality correlated at univariable analysis with recipient age, body mass index, mechanical ventilation, APACHE IV score, and platelets number. At multivariable analysis only APACHE IV score (HR: 1.07 [1.05–1.09, 95% CI]) independently affected survival. Conclusions: The APACHE IV score represents a powerful predictor of survival in patients bridged to HTx on ECMO support, and could guide candidacy of patients on ECMO. [ABSTRACT FROM AUTHOR]

Introduction: The use of veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) as a direct bridge to heart transplantation (BTT) is not common in adults worldwide. BTT with ECMO is associated with increased early/mid‐term mortality compared with other interventions. In low‐ and middle‐income countries (LMIC), where no other type of short‐term mechanical circulatory support is available, its use is widespread and increasingly used as rescue therapy in patients with cardiogenic shock (CS) as a direct bridge to heart transplantation (HT). Objective: To assess the outcomes of adult patients using VA‐ECMO as a direct BTT in an LMIC and compare them with international registries. Methods: We conducted a single‐center study analyzing consecutive adult patients requiring VA‐ECMO as BTT due to refractory CS or cardiac arrest (CA) in a cardiovascular center in Argentina between January 2014 and December 2022. Survival and adverse clinical events after VA‐ECMO implantation were evaluated. Results: Of 86 VA‐ECMO, 22 (25.5%) were implanted as initial BTT strategy, and 52.1% of them underwent HT. Mean age was 46 years (SD 12); 59% were male. ECMO was indicated in 81% for CS, and the most common underlying condition was coronary artery disease (31.8%). Overall, in‐hospital mortality for VA‐ECMO as BTT was 50%. Survival to discharge was 83% in those who underwent HT and 10% in those who did not, p <.001. In those who did not undergo HT, the main cause of death was hemorrhagic complications (44%), followed by thrombotic complications (33%). The median duration of VA‐ECMO was 6 days (IQR 3‐16). There were no differences in the number of days on ECMO between those who received a transplant and those who did not. In the Spanish registry, in‐hospital survival after HT was 66.7%; the United Network of Organ Sharing registry estimated post‐transplant survival at 73.1% ± 4.4%, and in the French national registry 1‐year posttransplant survival was 70% in the VA‐ECMO group. Conclusions: In adult patients with cardiogenic shock, VA‐ECMO as a direct BTT allowed successful HT in half of the patients. HT provided a survival benefit in listed patients on VA‐ECMO. We present a single center experience with results comparable to those of international registries. [ABSTRACT FROM AUTHOR]

This article discusses the use of venting strategies for patients undergoing venoarterial extracorporeal membrane oxygenation (ECMO) support for refractory cardiogenic shock. The article highlights the challenges and complications associated with ECMO support, including increased afterload to the left ventricle and the need for left ventricular decompression (LHD). Various LHD techniques are described, including active and passive venting methods. The article also mentions a recent randomized clinical trial that investigated the timing of left atrial venting during ECMO support, but the results did not show significant improvements in clinical outcomes. The article concludes by emphasizing the need for further research and clinical trials to explore the efficacy and optimal timing of LHD interventions in ECMO-supported patients. [Extracted from the article]

Introduction: Transsubclavian venous implantation of the Aveir leadless cardiac pacemaker (LCP) has not been previously reported. Methods and Results: Three cases of transsubclavian implantation of the Aveir LCP are reported. Two cases were postbilateral orthotopic lung transplant, without appropriate femoral or jugular access due to recent ECMO cannulation and jugular central venous catheters. In one case, there was strong patient preference for same‐ day discharge. Stability testing confirmed adequate fixation and electrical testing confirmed stable parameters in all cases. All patients tolerated the procedure well without significant immediate complications. Conclusions: We demonstrate the feasibility of transsubclavian implantation of the Aveir LCP. [ABSTRACT FROM AUTHOR]

Introduction: Since the 2018 change in the US adult heart allocation policy, more patients are bridged‐to‐transplant on temporary mechanical circulatory support (tMCS). Previous studies indicate that durable left ventricular assist devices (LVAD) may lead to allosensitization. The goal of this study was to assess whether tMCS implantation is associated with changes in sensitization. Methods: We included patients evaluated for heart transplants between 2015 and 2022 who had alloantibody measured before and after MCS implantation. Allosensitization was defined as development of new alloantibodies after tMCS implant. Results: A total of 41 patients received tMCS before transplant. Nine (22.0%) patients developed alloantibodies following tMCS implantation: 3 (12.0%) in the intra‐aortic balloon pump group (n = 25), 2 (28.6%) in the microaxial percutaneous LVAD group (n = 7), and 4 (44.4%) in the veno‐arterial extra‐corporeal membrane oxygenation group (n = 9)—p =.039. Sensitized patients were younger (44.7 ± 11.6 years vs. 54.3 ± 12.5 years, p =.044), were more likely to be sensitized at baseline ‐ 4 of 9 (44.4%) compared to 1 out of 32 (3.1%) (p =.001) and received more transfusions with red blood cells (6 (66.7%) vs. 8 (25%), p =.02) and platelets (6 (66.7%) vs. 5 (15.6%), p =.002). There was no significant difference in tMCS median duration of support (4 [3,15] days vs. 8.5 [5,14.5] days, p =.57). Importantly, out of the 11 patients who received a durable LVAD after tMCS, 5 (45.5%) became sensitized, compared to 4 out of 30 patients (13.3%) who only had tMCS—p =.028. Conclusions: Our findings suggest that patients bridged‐to‐transplant with tMCS, without significant blood product transfusions and a subsequent durable LVAD implant, have a low risk of allosensitization. Further studies are needed to confirm our findings and determine whether risk of sensitization varies by type of tMCS and duration of support. [ABSTRACT FROM AUTHOR]

Background: Noise pollution in intensive care units is a relevant problem, associated with psychological and physiological consequences for patients and healthcare staff. Sources of noise pollution include medical equipment, alarms, communication tools, staff activities, and conversations. Aims: To explore the cumulative effects of noise caused by an increasing number and type of medical devices in an intensive care setting on simulated patients with increasing clinical complexity. Secondly, to measure medical device alarms and nursing activities' sound levels, evaluating their role as potentially disruptive noises. Study Design: Observational simulation study (reported according to the STROBE checklist). Using an electronic sound meter, the sound levels of an intensive care room in seven simulated clinical scenarios were measured on a single day (09 March 2022), each featuring increasing numbers of devices, hypothetically corresponding to augmented patients' clinical complexity. Secondly, noise levels of medical device alarms and specific nursing activities performed at a distance of three meters from the sound meter were analysed. Results: The empty room's mean baseline noise level was 37.8 (±0.7) dBA; among the simulated scenarios, noise ranged between 45.3 (±1.0) and 53.5 (±1.5) dBA. Alarms ranged between 76.4 and 81.3 dBA, while nursing tasks (closing a drawer, opening a saline bag overwrap, or sterile packages) and speaking were all over 80 dBA. The noisiest activity was opening a sterile package (98 dBA). Conclusion: An increased number of medical devices, an expression of patients' higher clinical complexity, is not a significant cause of increased noise. Some specific nursing activities and conversations produce higher noise levels than medical devices and alarms. This study's findings suggest further research to assess the relationships between these factors and to encourage adequate noise reduction strategies. Relevance to Clinical Practice: Excessive noise level in the intensive care unit is a clinical issue that negatively affects patients' and healthcare providers' well‐being. The increase in baseline room noise from medical devices is generally limited. Typical nursing tasks and conversations produce higher noise levels than medical devices and alarms. These findings could be helpful to raise awareness among healthcare professionals to recognize noise sources. The noisiest components of the environment can be modified by staff behaviour, promoting noise reduction strategies and improving the critical care environment. [ABSTRACT FROM AUTHOR]

Enteral nutrition (EN) is one method of nutrition support for children and adolescents receiving extracorporeal membrane oxygenation (ECMO) therapy, and there are no guidelines for its use in this population. We conducted a systematic review to determine whether EN is effective and safe in children supported by ECMO. We searched the Cochrane Library database, MEDLINE, and Embase on Ovid in March 2023 to identify studies that evaluated children and adolescents who received ECMO and were treated with EN. Random effects meta‐analysis was used to estimate the odds of mortality with EN compared with parenteral nutrition (PN). A total of 14 studies were included in this review with 1650 patients (796 received EN). The median duration of ECMO was 5–10 days, and the median EN initiation time ranged from 23 h to 7 days. The pooled results suggest no significant difference in mortality with EN compared with PN (odds ratio [OR] = 0.77; 95% CI, 0.56–1.05; I2 = 26%). Exclusion of the only study that reported an increase in mortality resulted in a borderline significant reduction in mortality with EN (OR = 0.71; 95% CI, 0.51–1.00; I2 = 26%). The predictors of EN were male sex, older age, heavier weight, greater height, cardiac diagnosis, longer duration of ECMO, and use of venovenous ECMO. Most studies suggest no correlation between EN and complications. EN use in children and adolescents who receive ECMO does not appear to be associated with increased mortality compared with PN and was safe in terms of intestinal complications and feeding intolerance. [ABSTRACT FROM AUTHOR]

Background: The use of extracorporeal membrane oxygenation (ECMO) is associated with complex hemostatic changes. Systemic anticoagulation is initiated to prevent clotting in the ECMO system, but this comes with an increased risk of bleeding. Evidence on the use of anti‐Xa‐guided monitoring to prevent bleeding during ECMO support is limited. Therefore, we aimed to analyze the association between anti‐factor Xa‐guided anticoagulation and hemorrhage during ECMO. Methods: A systematic review and meta‐analysis was performed (up to August 2023). PROSPERO: CRD42023448888. Results: Twenty‐six studies comprising 2293 patients were included in the analysis, with six works being part of the meta‐analysis. The mean anti‐Xa values did not show a significant difference between patients with and without hemorrhage (standardized mean difference −0.05; 95% confidence interval [CI]: −0.19; 0.28, p =.69). We found a positive correlation between anti‐Xa levels and unfractionated heparin dose (UFH; pooled estimate of correlation coefficients 0.44; 95% CI: 0.33; 0.55, p <.001). The most frequent complications were any type of hemorrhage (pooled 36%) and thrombosis (33%). Nearly half of the critically ill patients did not survive to hospital discharge (47%). Conclusions: The most appropriate tool for anticoagulation monitoring in ECMO patients is uncertain. Our analysis did not reveal a significant difference in anti‐Xa levels in patients with and without hemorrhagic events. However, we found a moderate correlation between anti‐Xa and the UFH dose, supporting its utilization in monitoring UFH anticoagulation. Given the limitations of time‐guided monitoring methods, the role of anti‐Xa is promising and further research is warranted. [ABSTRACT FROM AUTHOR]